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research-article2014

QHRXXX10.1177/1049732314562892Qualitative Health ResearchNoland and Carmack

Using the Internet: General Article

Narrativizing Nursing Students’ Experiences With Medical Errors During Clinicals

Qualitative Health Research 2015, Vol. 25(10) 1423­–1434 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314562892 qhr.sagepub.com

Carey M. Noland1 and Heather J. Carmack2

Abstract The ways providers story their mistake experiences help to explain how providers understand medical errors and how they communicate about those errors. Communication scholars have slowly begun to explore the communicative nature of medical error experiences, with communication research becoming more abundant over the past few years. Missing from this discussion is how students in health professions, in this case nursing students, tell medical errors narratives and how the stories help them determine how to respond to mistakes. In this article, we explore how nursing students narrativize their medical errors experiences during clinicals. Qualitative interviews were conducted with 68 nursing students. The interviews were transcribed and resulted in a total of 1,261 single-spaced pages of data. We found that nursing students told three different narratives: (a) the “save the day” narrative, (b) the “silence” narrative, and (c) the “not always right” narrative. Finally, we discuss the implications of these narratives and their impact on nursing education. Keywords communication; education, professional; narrative inquiry; nursing; safety, patient

It is widely accepted that the two root causes of medical errors are the results of system errors and human error. Miscommunication is the primary root cause of 63% of sentinel events—the unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (The Joint Commission [TJC], 2011). Much technology and research have been devoted to identifying and decreasing causes of medical errors. In most cases, however, clinicians at the point of care remain the final safeguard against a dangerous situation adversely affecting patients. The Institute of Medicine (IOM; 2003) and TJC (2011) recognize the pivotal role that nurses play in keeping patients safe and the importance of clear and concise communication. Improving communication is a 2011 TJC National Patient Safety Goal. TJC (2011) included the following types of communication in their definition: oral, written, electronic, among staff, with/among physicians, with administration, and with patients or family. Nurses are well positioned to identify, interrupt, and correct medical errors and to minimize preventable adverse outcomes, yet there is scant research examining the role of nurses as the final defense against adverse events (Henneman et al., 2010). Communication failure plays an important role in causing medical errors (IOM, 2003). Clinical communication,

in particular, is highly complex and prone to error. Standardized communication approaches and tools might provide potential solutions to improve the quality of communication and prevent subsequent patient harm (IOM, 2003). It is important to understand the formal and informal learning environments where nursing students develop communication skills regarding medical mistakes. The socialization process into the medical field for nurses is unique, intense, and consequential. They face chaotic environments and inexperience, and yet, they are placed in life and death situations where they have the potential to make mistakes that cause irrevocable harm. During training, they are enacting the role of nurse, in situations when they are theoretically most likely to make mistakes because of inexperience and institutional factors. Several researchers found that many new nurses were unprepared for the negative interpersonal aspects of nursing (Davis & Luanne, 2005; Kelly & Ahern, 2009; Meissner, 1999) and that this might inhibit their ability to 1

Northeastern University, Boston, MA, USA James Madison University, Harrisonburg, VA, USA

2

Corresponding Author: Carey M. Noland, Northeastern University, Boston, MA 02115, USA. Email: [email protected]

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prevent, intercept, and report medical errors. Although nurses were students, they often held positive perceptions surrounding their impending role as a nurse: However, after one month of employment, it became apparent that nursing is comprised of a culture that embraced cliques which excluded them. The graduates were unprepared for “bitchiness” and the limited amount of assistance with unfamiliar tasks they received from registered nurses. (Kelly & Ahern, 2009, p. 910)

To mitigate these circumstances, Kelly and Ahern recommended that nursing curricula address socialization issues and provide students with skills to be proactive in preventing and responding to issues such as silence and aggression. Medical errors narratively represent compelling instances of Trouble with a capital T (Burke, 1954). How providers story their mistake experiences help to explain how providers understand medical errors and how they communicate about these errors. Over the past 20 years, communication scholars have slowly begun to explore the communicative nature of medical error experiences. Researchers have explored how physicians construct and enact responses to mistakes (Mizrahi, 1984), how providers disclose medical mistakes (Allman, 1998; Hannawa, 2009; Petronio, 2006), how physicians negotiate the aftermath of mistakes (Carmack, 2010; Noland & Carl, 2006), and how pharmacists are socialized to communicate errors (Noland & Rickles, 2009). We have also examined the socialization messages nursing students receive about communication and medical errors (Noland & Carmack, 2014). Missing from this discussion is how providers, in this case nursing students, story medical errors and how that helps them determine how to respond to mistakes. In this article, we explore how nursing students story their medical errors experiences, highlighting the narratives students learn during their clinicals. We start with a discussion of the literature of nursing students and medical errors, framing the discussion using narrative theory. After explaining our methodology, we present the narratives nursing students learn to story their medical errors experiences. Finally, we discuss the implications of these narratives and their impact on nursing education.

Narrativizing Mistake Experiences Many health care providers believe they are naturally gifted when it comes to communicating and do not need communication training. In a study of 103 Intensive Care Unit (ICU) clinicians at the Johns Hopkins Hospital, 82% of nurses, 74% of physicians, and 90% of surgeons expressed satisfaction with their skills. In stark contrast,

nurses rated only 2% of surgeons as having satisfactory communication skills (Aslakson et al., 2010). Nurses (75%) were most likely to report speaking to patients and families about prognosis, whereas only 40% of surgeons and 33% of physicians reported speaking to families. Nurses also felt their comments were less valued by the other groups. From these results, it is clear that there were significant differences between how surgeons self-rated their communication skills and how people who work with them rated their communication. These results are significant because medical doctors can establish the communication climate and set the tone for communication practices for an entire medical team. Woloshynowych, Davis, Brown, and Vincent (2007) argued that nurses play a “crucial role in maintaining communication flow” (p. 407), especially in chaotic environments such as emergency departments. In a study of communication flow in emergency departments, Woloshynowych and colleagues (2007) found that communication load could disrupt memory and lead to mistakes. To minimize errors, they recommended improving “communication between health care staff by reducing the levels of interruptions and minimizing the volume of irrelevant or unnecessary information exchange” (p. 407). Nursing students must learn to navigate both of these prescribed relationships. The communication skills training student nurses receive does in fact improve patient–provider communication (Zavertnik, Huff, & Munro, 2010). Positive, open patient–provider communication is essential to the health of patients and quality of continuity of care (Krautscheid, 2008). In a study of strategies used by critical care nurses to identify, interrupt, and correct medical errors, researchers found that nurses in critical care settings use 17 strategies to identify, interrupt, and correct errors (Henneman et al., 2010). To identify errors, nurses used eight strategies: knowing the patient, knowing the “players,” knowing the plan of care, surveillance, knowing policy/ procedure, double checking, using systematic processes, and questioning. Nurses used three strategies to interrupt errors: offering assistance, clarifying, and verbally interrupting. Nurses used six strategies to correct errors: “persevering, being physically present, reviewing or confirming the plan of care, offering options, referencing standards or experts, and involving another nurse or physician” (Henneman et al., 2010, p. 500). The communication strategies used to interrupt errors were often described as being “executed in ways that would ‘save face’ and maintain collegial relationships” (Henneman et al., 2010, p. 508). Although this approach seems reasonable, it might “delay interrupting errors that need to be addressed more directly to avoid potential adverse outcomes” (p. 508). Researchers caution that “passive aggressive approaches may also perpetuate a

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Noland and Carmack view of nurses as professionals unable to directly express their concerns” (p. 508). Some hospitals and nurse educators use the Situation–Background–Assessment– Recommendation (SBAR) communication, as “a strategy to optimally prepare student nurses to communicate effectively within the clinical setting” (Krautscheid, 2008, p. 4). For communication to be effective, the information must be “complete, accurate, timely, unambiguous, and understood by the patient” (Patak et al., 2009, p. 372). We can expect that errors will occur, especially with newer nurses. Henneman et al. (2010) studied the types of errors that occurred or were recovered in a simulated environment by student nurses. Results showed that “100% of nursing student subjects committed errors . . . this should be cause for concern about patient safety” (p. 18). Although the majority of errors occurred because students failed to verify patient identification and other critical information such as allergies, communication issues also accounted for mistakes. Common communication issues resulted from a lack of preparedness; nursing students called the physician without knowing critical patient information such as full patient name and pertinent history or assessment data (vital signs, urine output, and pain status). The authors found this type of communication issue particularly concerning given the key role nurses play in communicating critical data to other members of the health care team (Henneman et al., 2010) and that communication failures account for the majority of medical errors (IOM, 2003). Although Tija et al. (2009) recommended nurse preparedness when speaking to physicians as an essential tool to improve nurse–physician communication, the reality is that because of the systematic and expected delay of physician response, nurses are likely to be interrupted in performing another task that not only leaves them without vital information in front of them, but the very interruption itself increases the risk of error (Westbrook, Woods, Rob, Dunsmuir, & Day, 2010). In fact, Westbrook et al. (2010) found that the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors; specifically, each interruption was associated with a 12.1% increase in procedural failures and a 12.7% increase in clinical errors. In a study of how nurses experience making or being involved with medication errors, Stetina, Groves, and Pafford (2005) found three main themes: time is on our side, context counts, and reliance on systems. Respondents identified using the five rights (right time, right patient, right dose, right drug, right routine) to limit medication errors, although they found many, especially more experienced nurses, did not worry about the timeliness of the dose (or a missed dose) and rarely made a formal report about them. The authors’ second theme explored the

belief that “if something else going on in the unit or in the clinical setting had greater importance or required all the nurses’ attention to avert catastrophe, late medications and omitted medications were accepted as part of nursing judgment” (p. 177). Finally, the authors found that there was a reliance on new technology systems to doublecheck medications and prevent error. Given the inconsistencies in messages nurses received, it is important to determine how nurses are taught to communicate about errors, which result from these inconsistencies.

Narrative Standpoint Human beings are natural storytellers and we use stories as a way to understand and create our worlds (Fisher, 1984, 1985). Life is itself a storied experience (Somers, 1994). Narratives, as Somers (1994) argued, help to explain how “we come to know, understand, and make sense of the social world” (p. 606), a way of being in these worlds. Narratives serve as a way for people to communicate knowledge, feelings, values, and beliefs on a particular subject (Burke, 1969), or what Burke (1931/1968) described as “the element of self expression in all human activities” (p. 52). The task of communicating these values, beliefs, and knowledge is not always an easy one; we inevitably have to come to terms with changing beliefs, knowledge, and experience. Telling stories is how we make sense of these changes (Bruner, 2002). Moreover, how we negotiate these changes is influenced by our orientation(s) to reality (Polkinghorne, 1988). How we approach the world will inherently affect what narratives we tell and how we tell them. We use narratives not only to make sense of experiences and change, but also to claim, express, and enact our multiple and sometimes divergent identities (Langellier & Peterson, 2004). These elements make up problematics that narrative scholars face when we attempt to make sense of other (and sometimes our own) stories (Harter, Japp, & Beck, 2005). To understand human behavior, we have to understand how humans construct and use symbols in a time of crisis. For Burke, as symbol (mis)using creatures, humans create a social world through their action and do this in a poetic manner. Moreover, these symbolic actions are situated in an already established world, which can be molded and changed based on the crisis in which we are confronted. “Some decisions merely apply ways of thinking in which the person is already familiar. Others, in time of crisis, involve anything unsettling, and require an attempt to think differently about the situation” (Burke, 1954, p. xlvii). These moments of crisis in which we must react are those moments of Trouble with a capital T. Burke saw humans living in a state of constant flux and change, and

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continuously striving to maintain some stability in this chaos. Although humans are not ever able to have complete stability, they can develop communicative strategies that help them negotiate change. Uncertainty goes hand in hand with change, and humans are driven to reduce that uncertainty. We tell stories in an attempt to come to terms with uncertainty and (re)create stability. Narrative, then, is a way to think beyond “rational” scientific interpretations of the world (Fisher, 1985). Inherent to narrative is a concern for disorder and coherence: Narrativity involves characters embedded in the complexities of lived moments of struggle, heroes or victims who resist or accept the intrusions of disruption and chaos, preserve or restore continuity, and re-story meaning in their lives in the face of unexpected blows of fate. (Harter et al., 2005, p. 14)

In these disruptions, humans struggle with the lived experiences of self and others, to make sense of change and uncertainty (Bruner, 2002). Narrativity, embedding characters in the complexities of lived moments of tension, aids individuals in the preservation and restoration of continuity in the face of unexpected turns in our lives. This awareness, or emplotment, encourages individuals to become aware of what story they are enacting or are in at the particular moment in time (Mattingly, 1998). Emplotment makes connections between narratives, identifying the tensions and showing how they work together. It also helps individuals to make sense of the stories in which they are present and to make sense of past and future stories. Narrative, as the storied expression of the human experience, recognizes the multiple tellings and retellings of events. A single, unified story does not exist. Rather, narratives of experiences are constellations of experiences. Humans, over the course of a lifetime, encounter life events that become storied. Humans, however, do not experience these events separate or in a vacuum—multiple and sometimes divergent tellings of an event exist as stories converge and collide with each other (Boje, 2001). By recognizing this multiplicity, we recognize that lived experiences do not end with the completion of a telling of a story. Narratives are always partial and indeterminate, bounded and unfinished (Harter et al., 2005). Storytelling, then, is a collective and iterative enterprise; to understand an event, multiple stories and ongoing reflexivity are needed. Multiplicity situates narrative experiences as a way to “be” in and make sense of our worlds. Narrative is no longer a persuasive tool to impose perspectives on others, but rather a way to “acknowledge the diversity of storied lives and told and develop constructive ways of weaving the diversity of stories together to create new

ones” (Barge, 2004, p. 109). By positioning life itself as storied, narrative constitutes an “ontological condition of social life” (Somers, 1994, p. 614): the human condition. The significant role of nurses in the health culture of the United States and the importance of understanding how nursing students make sense of and communicate about medical errors on a daily basis led us ask two research questions: How do nursing students narrativize their medical mistake experiences? What stories do nursing students tell about their training about communication and medical errors?

Method and Procedures Participants and Data Collection This article is part of a larger project of nursing education practices and communication about medical errors. We used qualitative in-depth interviews to explore nursing students’ communicative experiences learning about medical errors. Data collection began after receiving university institutional review board (IRB) approval. A total of 68 nursing students were interviewed. Snowball sampling was used to recruit participants, beginning with contacts from a 5-year nursing program at a New England university. All nursing students had completed at least one clinical rotation. The majority of respondents were in their final year of school (see the appendix). Participants had a wide range of nursing experience, with many working for more than 2 years as certified nursing assistants (CNA) or as students in a hospital setting. A majority had worked at three or more health care facilities. Participants listed a wide variety of specialty interests, with the majority interested in pediatrics and emergency medicine. The nursing students reported making or being involved in a variety of medical errors (see Table 1) and how they communicated about those errors (see Table 2). The first author conducted individual in-depth interviews with the nursing students. Interviews lasted between 45 and 90 minutes and the researcher used a semi-structured protocol to allow participants to talk about their insights and experiences (Heyl, 2001). The interview protocol consisted of 38 questions focused on perceptions of the role of communication in nursing education, informal and formal communication training (both general training and training specifically regarding mistakes), accounts of excellent and poor interactions between health care providers and patients, and examples of memorable medical errors, which they made or participated in. The nursing students received US$5 Dunkin Donut gift cards to compensate them for their time. All of the interviews were audio-tape recorded with participants’ consent. All interviews were transcribed without

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Noland and Carmack Table 1.  Types of Nursing Student Mistakes. Type of Mistake

Categories

N

Mislabeling/Name mixup/Forgot label

9 (18.3%)

Forgot to document Administered incorrect medicationa

1 (2%) 10 (20.4%)

Negligence

17 (34.6%)

Performed unnecessary procedure

8 (16%)

Needle stick Violated HIPPAb Never made a mistake

3 (6.1%) 1 (2%) 16 (23.5%)

Forgot to label blood samples Patients had same name/same initials Put the wrong name on label Entered wrong vital signs Switched lab results Wrong dose of pain killer Gave medicine when it was discontinued (on nurses order) Gave wrong dose of medicine Gave medicine at incorrect time Not noting patient discomfort (e.g., pressure sore) or incorrect position of item (e.g. neck brace. Bottle fed baby rather than tube fed Ripped out tubing/lines Left tourniquet on after drawing blood Unsanitary when drawing blood/giving shot (didn’t have glove on, forgot alcohol) Pulled out catheter when full Left bed raised/forgot railing Performed procedure incorrectly (hanging platelets or drawing blood) Gave NPO patient food Blood draw Blood sugar Performed EKG on wrong patient Stuck self with dirty needle Tweeted about a famous person being in ED while working  

Note. ED = emergency department; NPO = nil per os; EKG = electrocardiogram; HIPPA = Health Insurance Portability and Accountability Act. a Also include two near misses. b The only error that received an official reprimand and involved the school.

Table 2.  Strategies Participants Used to Handle Mistakes. Strategy Fixed mistake and disclosed mistake Fixed mistake and did not disclosea Could not fix mistake, reported mistake Could not fix mistake, did not tell anyonea Mistake found, fixed by another Mistake found by another, could not be fixed Was immediately corrected by clinical instructorb

Frequency

Percentage

9 8 10 2 13 4 3

18.3 16.3 15.8 4.0 26.5 8.1 6.1 (2 near misses)

a

Seven participants did not disclose because of fear, not because of severity of mistake. Includes two near misses.

b

participants’ names to maintain anonymity. Transcription resulted in a total of 1,261 single-spaced pages of data.

Data Analysis The authors analyzed the data using a thematic constant comparative method (Glaser & Strauss, 1967). Each researcher read the transcripts several times to gain a complete understanding of participants’ experiences and

to ensure that any potential themes were grounded in the data (Strauss & Corbin, 1998). Data were analyzed interpretively, focusing on major ideas and meaning, rather than on specific speech turns or phrases (Lindlof & Taylor, 2010). We open-coded the data individually to identify potential themes we observed, then came together to integrate our findings into common, overarching themes. Consistent with Owen’s (1984) three criteria, a theme’s emergence was noted when there was recurrence

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(similar meaning was communicated but different words were used), repetition (the reiteration of key words and phrases), and forcefulness (indicated by vocal features such as inflection, volume, or pausing that set off certain portions of an account from others). We used a variety of quotations from participants to demonstrate rich rigor, thick description, and concrete detail (Tracy, 2010). Quotations from participants, identified only by year in nursing school, are used to illustrate themes. We removed vocal fillers and added punctuation for clarity. We approached the analysis with narrative sensibilities. Narrative inquiry provided us the opportunity to focus on nursing students’ storied ways of knowing (Cortazzi, 2001) and communicating how and what they learn about medical errors. These storied ways of knowing are often focused on moments of crisis or significant events, which shape the ways they act in the world (Cortazzi, 2001). Medical errors serve as moments of crisis for medical professionals (Carmack, 2010). Using a narrative sensibility allows us to simultaneously focus on nursing students’ personal experiences (Reissman, 2002) and the organizational forces, such as socialization and education, which affect how nursing students make sense of these experiences (Czarniawska, 2002). Although narrative theory provided a useful framework for making sense of nursing students’ experiences, the themes emerged from and are grounded in the students’ explanations.

Results Nursing students learn and perform a number of duties in their clinicals, often finding themselves juggling multiple duties simultaneously. A third year student listed some of the general duties she was required to perform: “Some of my general duties were assessment skills, finding abnormalities, practicing using medical terminology, transferring patients safely, safety and communication skills, confidentiality with HIPAA, medication administration, dosage, injections, and IV medications.” The student mentioned safety and communication skills, which included communicating about medical errors. Nursing students reported an uneven education regarding communicating about medical errors, with training ranging from formal in-class modules to informal education by the sharing of stories while in their clinicals. Of the 51 students who responded to this question, 43.4% said they had received formal training. The remaining 56.6% said they had received no training, but four specifically stated they had informal training (e.g., advice from a nurse). Of those who said they had formal training, all but one said they had attended an orientation at the start of work that showed them how to document a mistake. Only one student reported actually being taught

how to behave (remain calm) and to talk about the error with the patient and the supervisor. Of the people who reported no formal training, most said that they had talked about making mistakes in class, talked to other nurses about mistakes, or considered training in SBAR, a type of training that prevented mistakes and therefore could be considered an indirect type of error training. The informal socialization nursing students received during their clinicals taught students a number of important narratives to communicate about medical errors. These narratives help students to identify communication breakdowns, negotiate frustrations, and address the uncertainties associated with errors. Students also use these narratives to story their mistake experiences. Students learn and use (a) the “save the day” narrative, (b) the “silence” narrative, and (c) the “not always right” narrative.

The “Save the Day” Narrative The practice of nursing requires nurses to negotiate multiple responsibilities, one of which, as noted by the third year student above, is communication skills. However, these nursing students found it difficult and, in some cases, frightening, to communicate about their errors. Part of this had to do with the difficulty of accepting they made a mistake, as a fifth year student explained: It’s hard at first because it’s hard, owning up to a mistake and swallow your pride, but you quickly adapt since the hospital setting is much more critical than any other. Even the simplest mistake can result in the loss of a life.

Like other health professionals, nursing students are socialized into a health culture that demands excellence, which makes attempting to mistakes difficult. One thing students have to learn is to accept the loss of control and that they will make mistakes. Another fifth year student echoed this, simply stating, “But I mean it happens; everyone makes mistakes sometimes.” Many nursing students believe that mistakes happen and are important learning moments. A fourth year student recounted a memorable story about a Parkinson’s patient: If you’re not on your Parkinson’s meds, and you’re going for a 12-hour surgery, um, you’re out probably two or three doses of your meds . . . [I had to] hold this guy down while they tried to get an NG tube in him, they tried to get meds in him, um, and then draw blood off him . . . Um, but that was an issue that occurred in the OR . . . So yes it was a mistake . . . The nurses were the ones who picked up on it . . . [she] went, “Oh, I’ve seen that before,” and . . . knew exactly what was wrong, called me over right away . . . and the anesthesiologist wanted to give him Haldol, which, that’s the

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Noland and Carmack last thing you want to give someone who’s dopamine deficient, but, so it was one of those things where the doctor was new, and . . . they hadn’t thought about it, and the nurses who had been there forever were the ones who went, “Uh, hello? Problem. Fix it.”

Most students reported experienced nurses “saving the day” just because they recognized a mistake because of their know-how. This last narrative highlights the fact that the experienced nurse “saved the day” twice. First, she immediately recognized that the surgeons forgot to administer the Parkinson’s patient’s medication during a long surgery. Second, she averted disaster when the anesthesiologist prescribed the incorrect medication and might have caused serious damage to the patient. The student clearly remembers how the experienced nurse dealt with the physicians in an assertive manner and saw how other nurses could “save the day.” According to participants, when experienced nurses prevented, interrupted, or rectified mistakes, it was because of experience. When new nurses caught a mistake, however, it was because they double-checked something or because of a system. Many of the narratives involved were about an experienced nurse preventing a potentially fatal situation, such as this fourth year student’s story: In the PACU there was a patient whose blood pressure was very low and their heart rate was high and one of the doctors prescribed them medication and thankfully the nurse was a smart nurse, she had been working there a long time she knew about medication off the top of her head, um, and the medication they prescribed would have made the patient’s heart just race out of control and they would of ended up coding.

Knowing that others make mistakes gave these nursing students comfort because they knew they could turn to others to help if they made or almost made a mistake. One of the ways students learn to accept errors as part of nursing practice is by understanding that they are not alone. There are other health professionals, educators, preceptors, and students who are there to help them not make mistakes and to help them when they do make mistakes. A fifth year student pointed out, I’ve made mistakes . . . So if I made a mistake, all the orders that get transcribed are always double checked, so if I made a mistake by accident then somebody else will be there to kind of correct me and then the person double checking will let me know that I made a mistake.

This “double checking” system was a popular theme in nursing student mistake narratives, and it served as a way

to help students deal with the ramifications of making an error and reporting an error. Many students, like this fifth year student, count on themselves or others to catch things that “fall through the cracks”: I usually catch them, I want to say that the nurses are, the nurses and doctors, anyone can really look at the files . . . So it’s good that everyone double checks the system um but usually I catch my own mistakes or even sometimes it’ll pop up and I’ll be like “Oh that’s the wrong patient” you have to like make sure you double check everything.

Although experienced nurses catch mistakes because of their tenure, students are acutely aware of their need to double-check everything and they are confident that the system will catch mistakes (Stetina et al., 2005). Our participants also noted that the providers who needed to “save the day” were nurses. The students learn not only nursing but also how to help others deal with medical errors.

The “Silence” Narrative Another nursing student narrative revolved around the act of communicating about medical errors. For many students, they learned to not report errors, even the serious ones. A fifth year student recounted treating a woman who did not know about a medical error: This woman had something missed on her last recent colonoscopy and it ended up being cancer. But she was never communicated that it was pretty much the facility’s fault because they missed it in the first place. Her understanding was that she just now had colon cancer . . . It was really sad and the worst part about it is, that she will never know unless someone told her about the mistake. Colon cancer grows very slow too, they should have found it early on when she had her last colonoscopy and maybe could have done something sooner.

This student’s narrative highlights two instances of silence: The original silence from the hospital not telling the patient and the student’s silence and difficulty voice her concern. Part of this difficulty might be a result of experiences and mishaps being out of the nursing student’s control. A fifth year student recounted how during her first clinical rotation, she picked up an infant and accidentally pulled out the baby’s G-tube. Becoming distraught, she said, “I just didn’t want to approach the nurse and I didn’t want to tell her I pulled out his tube.” Many students reported that they were uncomfortable telling their nurse supervisor about these mistakes, which, they believed were still necessary learning experiences. A fifth year student

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mentioned how the medical error might have been prevented if her concerns had been respected: Sometimes the supervisors know that they are putting you in a compromising situation where you don’t know . . . It’s hard to convey to them that you feel uncomfortable because sometimes they don’t have a choice and you don’t have a choice and like the patients safety is paramount . . . but sometimes like you have to like speak up for yourself. Like, I can’t sit here. I don’t feel safe.

Unfortunately, even when students did speak up, it was often too late. A fifth year student explained the difficulties with communicating discomfort based on the status of other providers: There was a 16-year-old girl who needed a Nasogastric (NG) tube and she refused and they had to put her in restraints because she had pulled it out and they were trying to get it back in and the doctors called me in because they wanted me to hold her down, like hold her head straight so they could get the NG tube down and it was just a really uncomfortable situation for me but I was afraid to tell the doctors that I was uncomfortable doing it because . . . they’re the doctors.

It is important for students to have the communication skills to properly confront medical error as well as be able to voice concerns about uncomfortable situations. Conversations about medical errors often leave out the provider as a “second” victim (Carmack, 2010; Wu, 2000). The silence narrative told by nursing students includes the harm they experience from being silenced.

The “Not Always Right” Narrative Nursing students learn early in their nursing education that nurses make mistakes, and as they identified in the first theme, that someone more experienced is there to help save the day. However, what happens when the “experts” are the ones making the mistakes? For these nursing students, a final narrative they tell is that even the experts they turn to help them avoid mistakes are also making mistakes. This creates a tension for the nursing students: Who do nursing students turn to when their supervisors, preceptors, seasoned nurses, and other providers are not correct in their practice of nursing and medicine? For many of the nursing students, the responsibility of saving the day falls onto them as a learning experience. A third year student recalled a mistake made by an instructor when talking about medications: I had an instructor who told us [students] that we couldn’t give a painkiller in combination with another medication, but the instructor was mistaken and was thinking of

ibuprofen instead of Tylenol. Other students and I questioned it and looked it up. We told the instructor and she realized we were right. Even instructors can mess up, and that’s why everything is double and triple checked by several nurses. When you have six patients with several medications each, it’s easy to get confused and make mistakes.

This student’s story illustrated how the students knew something was wrong and worked together to find the correct answer. Students seemed more willing to confront the mistakes of their preceptors when they had time to research and when they were in numbers. Others were willing to be assertive on their own. This fourth year student recounted how she stood her ground and was not concerned with what the nurse thought of her: I’ve corrected another nurse, um who is there a little bit longer . . . and she asked me to draw the blood for her and I said, “Well can you hand me two of the blue tubes?,” and she went, “You don’t need two of those,” and I went, “Actually, you do,” and I explained why, and she said, “Well I’ve been doing it for years without two and it’s fine,” but handed me two tubes. Was sort of snipey about it, but still handed me the blue tube and let me do my job the way I wanted to do it. So, um, I have no issue with it, you got an issue with me, I don’t really care.

This student’s narrative is concerning because the seasoned nurse broke protocol and encouraged the student to follow incorrect practice, confirming the findings that when nurses are in a hurry, it is acceptable to take shortcuts (Stetina et al., 2005). Indeed, some of the most troubling narratives involved poor modeling on the part of the preceptor. Another student described a situation where she was asked to give a patient enemas every hour and it was not working. The patient was in severe pain and was raw from the enemas; however, the physician would not listen when the student tried to tell him it was not working. After 3 days of treatment failure, the physician finally changed tactics. However, the patient suffered this whole time and the student was asked to perform a procedure she was extremely uncomfortable with. She did comply with the physician’s orders in the end. Along dealing with incorrect “experts,” students also struggled with errors caused by technology. This was especially difficult for students because preventing or fixing a technology error often required them to understand the technology. This adds an additional layer of knowledge for nursing students, as explained by a fourth year student: Um, at first my heart dropped and I was like oh, no like, what’s going to happen? And I quickly started thinking, like,

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Noland and Carmack oh I hope there’s like a-a medication, like an antidote . . . And then I did feel a little silly because it clearly did say in the computer not to be given until noon. Um, but then at the same time it was frustrating that I was able to remove it from the Pixus . . . It shouldn’t have been allowed for me to take it out.

Not only was this student panicked about the drug error, she was upset that the machine incorrectly dispensed the medication in the first place. This illustrates that student nurses learn early to rely on systems to catch errors. Other students identified a combination of technology and human error made by those in charge, which poses more challenges for students, as illustrated by a fifth year’s scenario: With any sort of computerized orders or written orders, doctors will write them wrong and they’ll write down a wrong dosages or for the wrong patient and you have to double check your orders and make sure that it’s what you and that physician have talked about already or it makes sense . . . Say a patient, another patient, next door to the patient with the low magnesium has a high magnesium and you read an order that says give this magnesium to this patient. You look at the labs and say, but they have high mag. Mag can kill you . . . I’ve seen several incorrectly written orders that a nurse has had to call and clarify and get the order rewritten.

This student’s explanation is telling, because the scenario speaks not only to the difficulty in dealing with a dual error but also to how issues of hierarchy can affect communication about the error. Understandably, it is difficult to confront someone who is making a medical mistake, but it is essential for preceptors, instructors, and other providers to model appropriate communication and proper techniques to students. As one fifth year student bluntly told a physician in response to not following the doctor’s orders because they violated protocol, “It’s my license on the line.”

Discussion Nursing students retold narratives, which underscore the uncertainty and disruption associated with learning nursing, which included making medical errors. For the participants in this research, they narrativize their experiences by telling narratives about “saving the day,” silence, and experts making mistakes. The nursing students clearly felt responsible for the errors, even when the error occurred because they followed their supervising nurses’ orders. As one participant said, “I should have double checked. It’s my fault.” At the same time, most students regarded mistakes as inevitable. Given the fact that most participants felt errors were inevitable and they were

responsible, their narratives reflect how they struggle to reconcile these issues. All of these narratives reinforce a larger medical mistake narrative: Providers make errors, but they still struggle with not being perfect. For the most part, students recalled supervisors as grateful to the students for their assistance in catching and preventing medical errors. The most negative comment in the data was when the student described situations that “can be super touchy,” but no real negative consequences of preventing or intercepting a medical error were reported. Even when students were asked the question, “Have you ever been spoken to in an inappropriate manner or yelled at during your training?” they did not report being yelled at during or after error interception. Although they had many accounts of being yelled at by a supervisor, very few had to do with committing a medical error. Given these findings, it is important to think about the implications of assertive communication use. Is it students’ perceptions that they cannot intercept a mistake in an assertive manner? Do they just need the confidence? What role does the institutional/departmental culture play? How do interpersonal issues factor in? In other words, what are the real and imagined barriers to using assertive communication to prevent and intercept mistakes? Participants were taught to report mistakes and tell someone, but were not told how to do it and often did not report their mistakes when they occurred during their training. This is especially interesting given that the participants recognized that small errors could lead to big mistakes and serious patient harm, yet they hardly reported their small errors. Also, participants tended to focus on medication errors and conceptualized mistakes as medication errors. However, when students shared their narratives, many stories emerged that were not medication errors, they were procedural and knowledge errors (Simpson, 2005). Although students were able to more clearly conceptualize medication errors, they found themselves more often experiencing procedural and knowledge errors. This might be because of the reliance on automated medical systems designed to help administer medications. It might also be because one of the activities nursing students are allowed to do on their own is to administer medication. Finally, participants described mistakes as common and out of their control and necessary for learning. Narratively, this poses some unique challenges for how to make sense of the narrative of medical errors. What does it mean to be out of control? Are mistakes truly out of their control? Are they inevitable? How should nurse educators frame medical mistakes? How do we reconcile the fact that participants conceptualize medical mistakes as both inevitable and unacceptable—is there really “no room for mistakes,” as many participants stated?

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Practical Implications Professionals and academics involved in nursing training could teach and model assertive communication when it comes to medical mistakes. This includes discussing mistakes they make personally as well as mistakes they witness others making. Training would also serve to increase students’ overall communication competence and make their socialization process smoother. Many participants said that they talked about making mistakes in class, but no tangible suggestions were made to address them. Also, not many supervisors shared personal accounts of their mistakes, how they handled them, and how they wish they had handled them. Supervisors/professors could provide concrete suggestions for how to communicate when a mistake is made and what to do when they are in an uncomfortable situation that could result in a mistake. Training students to gauge their skill level is important—for example, training to help students assess if an anxiety-provoking situation is truly dangerous to them, or if is it something they have to do for the first time and they are experiencing normal levels of anxiety associated with first time procedures, would be beneficial. Finally, instructors can help students understand what they can and should expect in terms of supervision. If they are not adequately supervised, how do they address it? How do they talk about it? What are some ways they could confront an “old school nurse” who “has done it this way for years” and wants them to do it the same way? In addition, students could benefit from communication training on how to talk to their supervisors about issues such as workload and being overwhelmed. From an organizational standpoint, there needs to be a cultural shift in the education and practice of nursing. A student is a cultural outsider and in a position to recognize failed systems and harmful, dangerous shortcuts that many health care providers engage in to support faulty systems. The narratives told by nursing students highlighted how nursing students were often the ones who had to step up and “save the day.” In these instances, the students become an “expert”; however, they are still learning and practicing in a cultural system that frames students as unknowledgeable. One of the cultural shifts required is from the traditional teacher–student relationship to one of co-learners. This is especially true for students who have other professional health degrees, such as physicians’ assistants and nurses’ aides. Teaching and learning should be transactional rather than unidirectional. In addition, nursing education, be it in clinicals or before, needs to include skills training for nursing students to communicate in the moment. What is the best way for nursing students to confront someone who is making a procedural error or violating infection control

standards? Students know right from wrong and they often know of the latest safety protocols. It became clear listening to the tapes that some of the communication about mistakes came down to individual personality traits; some interviewees were simply more assertive and confident than others. We need to examine what measures clinical instructors can take to make communication about mistakes less reliant on personality and more standard throughout the training process. One of the more popular slogans in patient safety is “See something, say something.” Instructors and trainers need to identify and teach effective communication strategies to students to prevent medical errors.

Limitations and Areas for Future Research There are several limitations with this research. The patient was absent from most narratives. Nursing instructors teach that the central focus in medical errors should be the patient, but we focused on the students’ voices instead of the patients’. Also missing from the narratives were the instructors’ voices. In addition, these narratives might be geographically bound; all of the nursing students were involved in programs in the New England area of the United States. It is possible that nursing students in other regions of the United States would tell different narratives. There are many avenues for future research. First, the nursing student–preceptor/nurse supervisor relationship is of primary importance. Existing research does not address the type of communication about mistakes that takes place between this dyad. Although there is research on mentoring (e.g., Kelly & Ahern, 2009; Krautscheid, 2008), overall, the literature seemed to indicate that student nurses were reluctant to constantly seek out the advice of their supervisors because of a number of factors. Nevertheless, it seems from the interview data that most student nurses felt supervisors shared in part of the blame for mistakes. Second, it would be valuable to study the student–preceptor/nurse supervisor relationship and the kind of interactions that take place in the event of a mistake. In this research, only one side of the story (the student nurses) was reported. It is unclear how nursing students reported potential mistakes (that later became mistakes) to their supervisor. For example, did they stress to the supervisor that they felt this was extremely important and needed immediate attention? Or were they hesitant and unsure in their report and thus led their supervisor to believe the situation was not that serious? Observation of the dyadic relationship would be essential in answering these questions and overall could significantly help to improve the communication about mistakes and potentially lessen the incidence of mistakes.

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Appendix

Authors’ Note

Participants’ Year in School.

A version of this article was presented to the Annual Convention of the National Communication Association, November 2014, in Chicago, Illinois, the United States.

Year in School Second Third Fourth Fiftha

Frequency

Percent

 2  8 23 30

3 12.6 36.5 47.6

a The majority of participants attended a 5-year undergraduate nursing program.

Participants’ Average Length of Time Training in a Hospital or Clinical Setting. Length of Time Four months More than 6 months More than 1 year More than 1 year and 6 months More than 2 years

Frequency

Percent

1 5 16 7

1.5 7.9 25.3 11.1

34

53.9

Number of Training Experiences Greater than 3 Months in Duration. Number of Experiences One Two Three Four Five or more

Frequency

Percent

8 15 16 8 16

12.6 23.8 25.3 12.6 25.3

Area of Specialization Students Were Considering. Area of Care General Medicine Labor and Delivery Public Health Women’s Health ICU Pediatrics Nurse Practitioner Emergency Psychiatric PACU NICU Geriatrics Oncology Medical/Surgical Neurology

Frequency

Percent

1 5 3 5 14 18 2 10 3 1 2 3 3 4 1

1.3 6.6 4.0 6.6 18.6 24.0 2.6 13.3 4.0 1.3 2.6 4.0 4.0 5.3 1.3

Note. Some participants listed more than one area of interest (n = 75). ICU = Intensive Care Unit; NICU = Neonatal Intensive Care Unit; PACU = Post-Anesthesia Care Unit.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Carey M. Noland, PhD, is an associate professor in the Department of Communication Studies at Northeastern University in Boston, Massachusetts. Heather J. Carmack, PhD, is an assistant professor in the School of Communication Studies at James Madison University in Harrisonburg, Virginia.

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